Travel Health Matters

How about the water?

2012-01-25T20:24:00.006-05:00

Unsafe food and water make more people sick than anything else when they travel. Traveler's diarrhea,which can also include vomiting, fever and dehydration, can ruin a trip quickly. The most common question I get in the travel clinic is, “Can I drink the water there?”

CanIdrinkthewater.org is a web site (which is also available as an iPhone app) that quickly answers that question no matter where you are traveling.

If you can’t drink the tap water, plan ahead to protect yourself. Stay hydrated with bottled water. Make your own ice cubes with bottled water. If you have access to a freezer you can bring a small flexible ice cube tray with you. It may make sense for you to bring a SteriPen to sterilize the water yourself. Wash produce yourself with clean water.

If you can’t drink the water in a country, it also means you can’t eat foods washed in that water. Avoid salads and fruits that cannot be peeled by you. Coffee, tea, carbonated beverages, alcoholic drinks and bottled water are safe but not ice cubes or crushed ice. So, no blender drinks with those little umbrellas. Don’t brush your teeth with the tap water. Tie a hair scrunchie around the faucet to remind yourself not to automatically drink from it or brush your teeth in it. Keep your mouth shut in the shower.

Always use common sense. If a place doesn’t look clean, no matter where it is, play it safe and go elsewhere if you can.

Otherwise remember boil it, cook it thoroughly, peel it or forget it.

Avoiding Winter Travel Woes

2012-01-14T15:01:00.004-05:00

Here are a few suggestions to help you cope with winter travel.

Right phone numbers- Keep important phone numbers handy for use during travel. Program your cell phone or write it down and keep it on you. You will need your airline, car rental, hotel, travel insurance company, etc. If your flight is late or cancelled, you can avoid the long line at the airline desk by calling them on your cell phone to make your arrangements. If you have travel insurance, call them and they will assist you.

Fly early in the morning if you can. These flights are the least likely to get delayed or cancelled. You will have more opportunities for rebooking that day. It’s no fun sleeping overnight in an airport because you’re stuck.

Check flight status early and often. You can do this from a computer, smart phone, and tablet or at the airport. Always check the departing and arrival boards at the airport.

Fly direct. If you have a connecting flight you also need to monitor the flights and weather at that destination, too. If you do have a connecting flight and the weather looks bad there, call the airline and see if you can reroute to another connecting flight.

Remember to bring your cell phone and keep it charged. Be prepared for the worst and hope for the best for easier winter travel.

Unique Holiday Gift Ideas

2011-12-12T14:37:00.006-05:00

Looking for unique gift ideas? I found ‘em. These neckties, boxers, scarves and more combine health, education, science, art and fashion. Infectious Awareables has something for everyone on your list. How about a dust mite tie? A polio scarf? Or Ebola boxers?

Unless you know your micro, you’d never know exactly what the abstract design is that you are wearing. Is that dental plaque bowtie or HIV?

There must be at least one person on your list that’s fascinated with science, microbiology or health care. These are not just for the fashion conscience but also for those who wish to start amazing conversations that can lead into mini micro lessons just about anywhere you go.

So don’t wait, wash your hands and go to Infectious Awareables and be the hit of the office grab this year. Won’t your boss be impressed!

Choosing a Travel Clinic

2011-10-05T14:35:00.008-04:00

The American Travel Health Nurses Association (ATHNA) offers these guidelines for consumers to help them choose a travel clinic.

1. Look for a clinic that offers customized care. Your pre-travel visit should include an in-person assessment and focus on an individualized plan specific to your health history, destination, and potential activities.

2. Ask about counseling to reduce the non-vaccine preventable risks of travel. Pre-travel preparation is more than just immunizations. Your visit should include sufficient time to address issues such as malaria, altitude illness, dengue, jet lag, and traveler's diarrhea.

3. Ask about clinic charges and payment. Charges vary widely and many travel health costs are not reimbursed by health insurance. Costs for vaccines continue to rise. Know that some clinics work on a commission basis and providers receive a percentage of the total bill. Be aware of potential conflicts of interest.

4. Inquire about the training and experience of your provider. Quality pre-travel care is offered by many health professionals, including MDs, NPs, RNs, PAs and pharmacists. However, there are few national standards for entry into practice. While membership in a professional organization, such as ISTM, ASTMH, and ATHNA, is no guarantee, it may suggest a larger commitment to the specialty.

5. Think about finding a clinic early, even before you make final payment for your trip. While most travelers need only one visit to prepare for their journey, others may require multiple visits. Ideally, you should start 4 to 6 weeks ahead of departure. However, it is never too late to receive pre-travel care. Travelers seen just hours before a flight can still reduce important travel risks.

Dental Malfunction

2011-08-29T07:30:00.002-04:00

When I was 12, I chipped my front teeth. I have had caps since then and over the years, they have fallen off and one cracked when I bit into a chicken leg once. Fortunately, I was home and was only inconvenienced because it happened on a weekend. But what if I was traveling? How available is quality dental care where you travel? What would you do if a filling came out, a bridge broke or a cap came off?

A year ago, a travel clinic client told me she had been on a cruise ship when she had a dental malfunction. She went to the infirmary. They pulled out an emergency dental kit, made a temporary repair and charged her $200. She knew she could’ve made the repair herself but didn’t have the right stuff. She asked if emergency dental kits were available for sale. And they are. For about $25.

The dental emergency kit allows you to do basic, temporary repairs for most dental emergencies. There are several types on the market and most include tweezers, a dental mirror, floss, picks, cement, temporary fillings and topical and oral analgesics. This compact kit comes with full written directions and takes up little room and has a long shelf life.

Travel Health of New Hampshire carries one and it costs $25. Got caps? Get EDK- Emergency Dental kit.

Fight Germs with Style

2011-05-20T07:21:00.003-04:00

We have an arsenal of products to keep germs at bay these days- antibacterial soap, wipes, sprays, gels, face masks, gloves. In order for them to work, you have to carry them around with you, which can be a hassle when you travel. Some people walking aroung airports look like they should be walking around an OR. But now there is something new to protect you that you wear and actually looks good, too.

GermBana is a new antibacterial fabric that is soft and comfortable for you but kills germs including MSRA on contact. It does so by breaking down the negatively charged fibers in bacterial membranes with its positvely charged fibers. So, no smell or chemicals and it keeps its germ killing properties wash after wash. GermBana comes in black or khaki and is made into a pocketed scarf, neck/face gaiter and gloves. Go ahead, cough or sneeze into that scarf. Germs are killed on contact. Enviornmentally friendly, washable, good looking, and long lasting. A new, fashionable way to kill germs to add to your packing list.

Counterfeit Drugs Abroad

2011-05-14T08:07:00.005-04:00

Recently I saw a young woman in my travel clinic who was planning on spending the summer in India. She was behind on her immunizations and had made an appointment to find out what she needed but didn’t want any vaccinations. She wanted to know which malaria drug and antibiotics to use but planned on getting them in India to save money. She had heard they were easy to get and much cheaper there.

What she doesn’t know is that WHO (World Health Organization) estimates that 3 in 10 pharmaceutical products in the African, Asian and Latin American markets are fake. And 50 to 60 percent of anti-infective medications in parts of Asia and Africa have been shown to have substandard active ingredients. That means that many of the drugs purchased abroad won’t work properly, if at all.

Not only is this a risk to the traveler for contracting the very diseases they are trying to prevent but it is a public health risk to everyone. When a traveler is under-medicated he or she then becomes an evoluntionary vector in which drug resistant super bugs develop. The traveler then spreads these bugs as they travel and brings them home.

Counterfeit medications are posing an increasing threat to patient’s health worldwide, because they offer high returns and low risks for criminal organizations, the U.N. Office on Drugs and Crime (UNODC) said last week.

There are many ways travelers can save money when planning a trip. But doing so by purchasing medications and vaccinations abroad is a very dangerous and ineffective way to do so.

What do George Clooney, King Tut, Mother Theresa and JFK have in common?

2011-02-24T15:00:00.003-05:00

Malaria. A potentially fatal illness so named by the Italians for bad "mal" air "aria" thought to be caused by the marsh airs. It is actually caused by a parasite spread when the female anopheles mosquito bites someone who has malaria and then goes on to bite someone who doesn't. In colonial times we had summer outbreaks in Washington DC, Philadelphia and Boston. Malaria was controlled in the US by clearing the swamps and by mosquito eradication. But it still exisits in many places in the world and unsuspecting travelers can get exposed. Malaria exists in some places in the Caribbean, Mexico, Central and South America as well as Africa, South East Asia, India, Pakistan and other surprising locales.

If you are traveling outside the US, you can go to CDC web site and look up malaria area maps. If you are traveling to a malaria area protect yourself by avoiding bites between sunset and sunrise covering exposed skin and using 30 % DEET. Talk to your primary care provider or travel clinic about taking pills to help prevent malaria. These need to be started before you leave, and are taken while you travel and for a week or a month after you leave the malaria area.

All it takes is one bite from one mosquito, one time. Protect yourself. For more information go to www.malariahotspots.co.uk.

It's not too late for a flu shot

2011-02-15T15:37:00.004-05:00

Flu shots in February? Yes. Flu is active all over the U.S. Getting a flu shot during flu season can still help protect you. Flu season sometimes lasts into May. If you get vaccinated now, your full immunity may take about 2 weeks , but you do get some protection right away. Limited protection is still better than no protection.

Flying on an airplane this winter will increase your chances of getting sick. Let's say you are headed on vacation. You are flying for several hours in an enclosed area with lots of people from all over the world, all breathing the same air and touching the same surfaces. Now, add to that, that the humidity of air in an airplane is close to that of the Sahara dessert.

Our mucous membranes that line our mouths and noses are our main defense against viral invasion. Dry air caused micro cracks in mucous membranes that then act as open doors to the viruses you inhale. It is estimated that your risk of catching a cold on an airplane is 100 times that of exposure on the ground. So, in about 1-2 days, the average incubation period for influenza virus, you come down with the flu- fever, chills, cough. You know the feeling. Not only have you ruined your vacation, but then in a few days you'll get on a plane to head home where someone else is going to breath your air and the whole process just continues.

So, why not just get a flu shot? Call your primary care provider or travel clinic. It's not too late and there is no shortage of vaccine.

Heading South Soon?

2011-02-07T16:12:00.004-05:00

Dreaming about a warm, sunny beach in a tropical paradise? If you are heading south this winter, I bet you are not dreaming of traveler’s diarrhea, dengue fever , or malaria , which can be found in Paradise, too.

To prevent diarrhea, don’t drink the water, brush your teeth in it, have drinks with ice cubes or frozen blended drinks. Don’t eat food unless it is piping hot and thoroughly cooked. No fresh fruit or vegetables unless they are peeled. Mangoes, papaya, pineapple and banana can all be peeled. It’s a very good idea to get vaccinated for hepatitis A, a viral infection of the liver, transmitted from contaminate foods and water. Staying at a resort that tells you their water is filtered? Still don’t drink the water and follow all the precautions because you don’t know what kind of filtration system is used and how well it is maintained. It is a good idea to bring a prescription antibiotic to self treat diarrhea just in case.

Avoid mosquito bites day and night. One bite from one mosquito can result in a case of dengue fever or malaria. Dengue fever, nicknamed broke bone fever, is increasing in the tropics. There is no treatment or vaccinations, so the only protection is by covering up and using 30% DEET insect spray all day and night. Find out whether you need to also take malaria pills before you go.
To get information, consult a travel clinic and the CDC web site on travel health. A visit to a travel clinic will be sure your immunizations are current and will provide you with prescriptions for traveler’s diarrhea or malaria. Don’t want to worry about malaria or dengue fever? Consider talking to a travel clinic before you book your trip for advice.

So, when you are laying on that beach , the only thing you’ll need to worry about is getting sunburned. Then the only things you’ll bring home will be great photos, good memories and a few souvenirs.

Clean Water in the Palm of Your Hand

2010-11-27T09:55:00.003-05:00

Finding an adequate supply of clean water is a challenge in many places people travel. Drinking only clean water is your best defense against contracting many diseases, especially traveler’s diarrhea. Bringing your own water isn’t always feasible and many products to purify water left behind chemical tastes and took a lot of time to process.

But now there is a product that works in minutes and fits in the palm of your hand. The SteriPen sterilizes a 16-oz. cup of water in less than a minute with ultraviolet light that eliminates over 99.9% of viruses, bacteria and protozoa that cause waterborne illness. It doesn't need to be plugged in and it’s portable, packable and powered by AA batteries.

You can use it for international travel or camping in the USA. This past week, a group of relief workers heading to Haiti, purchased SteriPens from us to help prevent cholera.

Looking for a holiday gift for that hard to please traveler? Check out SteriPen.

The Question I Hear Most Often Is

2010-10-02T12:46:00.005-04:00

Why should I go to a travel clinic before a trip?

Here are the top 10, some of which might surprise you.

1. We do all the internet leg work for you. We consult with experts in the US and Switzerland daily to stay on top of the latest outbreaks, safety concerns and vaccine recommendations and requirements.

2. You may not be fully protected against illnesses present in other countries, such as polio and typhoid. We can discuss routine, recommended and required vaccines.

3. You’ll get a prescription for the medication that is best suited for you (side effects, cost, and convenience) to prevent malaria, a potentially life-threatening disease that is present in many tropical countries.

4. We’ll tell you how to prevent and treat traveler’s diarrhea, a condition that can ruin your trip and stay with you for weeks after you return.

5. We’ll tell you whether you will have any problems with your regular medications or treatments while traveling. Are any of your prescriptions controlled substances?Are you a diabetic carrying syringes? Use medications that need refrigeration? Use a C-Pap machine?

6. There are many diseases for which there are no vaccines, such as dengue fever, which you may not have ever even heard of before. We’ll tell you how to prevent it.

7. We’ll teach you about food and water precautions.

8. We’ll give you tips and treatments for jet lag.

9. You’ll receive a wealth of suggestions for staying safe, including accident prevention tips, embassy contact information, overseas health and emergency evacuation insurance and local health care resources.

10. We carry specialty products to keep you healthy and safe- dental emergency kits, first aid kits designed for your destination, syringe and suture kits, oral rehydration solutions, insect control products, and much more.

Time to Talk about Flu Vaccines

2010-08-30T08:22:00.003-04:00

There are new recommendations about flu vaccination this year. The biggest change is that flu vaccines are now recommended six months of age or older (in the absence of medical contraindication). There is no preference given to the intranasal or the injection form, for healthy, non-pregnant persons age 2-49 .Children from 6 months to 8 years of age will again require two doses of influenza vaccine, unless they received at least 1 dose of H1N1 vaccine during the 2009-2010 season and two doses of seasonal influenza vaccine (either both last year or in two different years).

The 2010-2011 seasonal influenza vaccine is already available. We received our shipment 2 weeks ago. It contains three strains – the 2009H1N1 antigen is the same as the H1N1 vaccine from last year, the H3N2 is a new antigen and the influenza B strain was in last year’s seasonal vaccine. Persons with a history of influenza or vaccination last year should be encouraged to get the vaccine again this year, due to the natural waning of the antibody response and the added protection of the new antigen in this year’s vaccine. It is not too early to begin vaccinating now, since we do not know if the season will peak early, as it did last year (at the end of October).

There is also a newly approved high-dose influenza vaccine for persons 65 years of age (Fluzone High-Dose). It is an alternate inactivated vaccine and it contains four times as much hemagglutinin antigen as the standard dose vaccine and is more costly. Neither CDC nor ACIP is expressing a preference of one vaccine over another for this age group at this time.

Call us today at 603-528-4304 for your flu shot.

Get Your Feet Wet

2010-08-10T09:23:00.007-04:00

On January 14, 2011 Gail Rosselot, ANP, CTC, FAANP and I will be escorting a group aboard Cruise West’s “Pacific Explorer” through Panama and Costa Rica. This 9-day 10-night cruise begins in Panama, transits through the Panama Canal and heads along the Pacific coast north toward Costa Rica’s beautiful Los Suenos Marina. We are offering a continuing education program in travel medicine for primary care providers and those in travel medicine.

Highlights of the trip include swimming, snorkeling, kayaking, hiking and visiting botanical gardens, national parks, and spending the day with an indigenous tribe only accessible by Zodiac boats.

This trip of a lifetime is open to those with a sense of adventure and although workshops will be offered to NP’s, PA’s, RN’s and MD’s. But anyone interested in exploring Central America is welcome to join the group (even if you decide not to participate in the conference) and group discounts apply to all.

I have traveled with Cruise West and I am impressed with the level of service they offer. The ship’s capacity is 100 passengers. Everyone is so friendly and the naturalists onboard are are so well informed about the local wildlife, birds, peoples and culture. The solo traveler as well as the one who brings friends or family will all feel welcome.

Unpack once and be prepared to be awed by the beauty that is all around you. The rates include everything except alcohol, and tips are not required or expected. It is such a relaxing way to travel.

This is not a typical cruise ship. Getting dressed up for dinner means putting shorts on over your bathing suit. Space is limited so sign up today.

For full information visit www.unique-workshops.com.

Fun in the Sun

2010-07-11T09:58:00.003-04:00

A sunburn can not only increase your risk of skin cancer but put a big damper on your vacation.

Here’s your best defense against too much harmful UV radiation.

Prevent sunburns by covering up. Shirts, hats, shorts, and light weight pants shield your skin. Many companies make clothes with higher UV protection than regular clothing, too. Stay in the shade. Sit under a tree, use a beach umbrella or even take a beach tent or canopy with you , if possible. Some beaches rent umbrellas or covers for very reasonable rates. Avoid midday sun. Plan activities early morning or later in the afternoon. Don’t forget to protect your eyes with sunglasses and a visor.

Now use your sunscreen. Some sunscreens prevent sunburn but not other types of skin damage. Look for a product with broad spectrum coverage. Pick an SPF based on your skin type, the time you will be outdoors, what types of activity you’ll be doing and of course, the weather. Don’t be fooled into thinking you don’t need sunscreen on a cloudy day. Many woman use sunscreen regularly to protect from cosmetic skin damage. Everyone knows to use sunscreen on kids. But studies show men don’t use sunscreen often enough.

Thumbs Up Tenderfeet

2010-06-14T05:54:00.006-04:00

Last week I returned from a safari to Kenya with Prestige Plus , a travel club of Laconia Savings Bank. Twenty seven of us rode Land Rovers through miles and miles of some of the most beautiful landscapes, sunrises, and game reserves on this planet. The expanse of the parks and numbers of the animals made me feel quite insignificant. That is until our last day, when we were to visit an orphanage in Nairobi. Like LSB, Collette Vacations is a strong supporter of the communities it does business with and assists local efforts to improve the lives of those who need some help. It brings its travelers here to see a part of Kenya not usually visited by tourists. We brought donations and were asked to help open the new building of the Tenderfeet Education Center. On the way, we stopped at a local grocery store and bought school supplies to bring with us. Another way we got to see Nairobi up close.

We drove through a slum of 60,000 people to this small cement building that educates and feeds and gives hope and love to 80 orphans from AIDS ages 2-10. After Valerie Drouin, VP and Rodney Dyer, Chairman of the Board of Laconia Savings Bank, cut the ribbon the children sang a song about Kenya. In the chorus they sang Valerie has a friend in Kenya, and Rodney has a friend in Kenya and the visitors all had a friend in Kenya. They were so happy to have us and so very grateful for our support. And invited us to please come back.

There are many plaques throughout NH thanking Laconia Savings Bank for its help. But the one in Nairobi is quite special.

I did feel that the money I spent on safari helped the local economies. But what I left there made a far greater impact, perhaps on me more than them.

Safari to Kenya Day 1

2010-05-26T23:37:00.000-04:00

Between watching the winds that determine volcano ash direction and the politics of a strike, getting to Nairobi, via London, has been a challenge. After a long flight, it felt great to stretch my legs as I walked through Heathrow. As with any large international airport once you exit the plane you have quite a distance to go to exit the airport. As I walked down long corridors, up and down stairs, took a train and weaved through the cues, I wondered how far I'd walked. I sat beside an older woman on the bus to our hotel and she estimated we'd probably walked one mile, perhaps more. She doesn't travel often and was very surprised that we had to walk so far in the airport. I was thinking it wasn't nearly as long as other airports I'd been to.

I didn't ask my seat companion her age. But it got me thinking. How realistic are the expectations of some older, less experienced travelers about the physical aspects of their trips ?Those of us in travel health need to be more aware of how fit our clients for their travel. Originally we had a connecting flight with a two hour layover. Not much time to traverse a large airport especially for slower goers.

After an entertaining meal at a local pub (fish and chips, of course) we leave London for an early flight to Nairobi.

No Ice, Please

2010-05-18T10:35:00.002-04:00

Food and water precautions are a frequent topic of conversation in travel clinics. There are so many places in the world where you simply can’t drink the water. And that means no ice, either. So what do you do when you forget to tell someone no ice and you are brought a drink with ice in it? You call the waiter over and ask for one with no ice. He walks away and returns with a glass with your beverage and no ice. But what happened?

Did the waiter remove the ice with his hands? Once the ice was removed, did fill the glass with more of the drink? Maybe, he poured out the drink and filled the same glass with a new drink. Or, maybe he got a new glass with a fresh drink. Problem is, you don’t know. So, what do you do?

If I get a drink with ice, I send it back and say I changed my mind and order a beverage that is carbonated in the bottle or order something that has been boiled, such as hot tea or coffee. You could ask for a bottle of water and ask to open the bottle yourself but you can’t be sure that it has been processed with sanitary water under sanitary conditions or hasn’t been tampered with.

The alcohol in alcoholic beverages will not kill bacteria lurking in ice cubes. But, you could order beer or wine.

A Tale of Two Students

2010-04-28T07:35:00.005-04:00

This is the true story of Jane and Kathy, who are roommates going to Nicaragua for a semester abroad. They were advised to go to a travel clinic prior to departure. Jane is trying to save money and since most travel clinics don't accept insurance she went to her primary care provider. Kathy came to our travel clinic and got a statement to send in to her insurer for possible reimbursement direct to her.

Jane received a hepatitis A vaccine (cost $95 plus $30 to administer the vaccine) and got prescriptions which she filled at her pharmacy for Lariam for malaria ($204) and oral typhoid vaccine ($65). She paid her $25 copay for the visit and was told they would submit it to her insurance.

Kathy got a hepatitis A vaccine ($85 and we don't add an administration fee) and oral typhoid vaccine($66) that was packaged in a small Styrofoam cup with ice and a lid to keep it cold until she got home. She filled a prescription for choroquine for malaria ($85) at her pharmacy.

Jane said nobody told her to refrigerate her typhoid vaccine which she had left out. She looked at the small box and there was a sticker that said refrigerate it but she didn't see it. She called the pharmacy who said the vaccine was no good and they couldn't take it back or replace it. She would have to call her PCP for a new prescription and have to pay for it again.

She asked Kathy why she had a different malaria prescription. Kathy said she was told this one was less expensive and safer for someone with a history of depression. Jane is taking an antidepressant that she gets filled through her mail order pharmacy. She called the pharmacy again and asked about Lariam and depression and was told said she shouldn't take the Lariam and to call her PCP. Lariam was not returnable or refundable.

She called her PCP who agreed that Lariam might cause problems for her and that she could have a prescription for choroquine. Her PCP doesn't usually write prescriptions for malaria prevention.

Jane was not happy. She was out $270. Then she got a statement from her insurer saying that her travel visit and hepatitis A with her PCP was not covered due to her deductable and she owed them $250 less her copay. Her total cost now is up to $605.

Kathy however spent $283 for her visit and $85 for her prescription for a total of $368. Going to a travel clinic first? Less expensive, less aggravating and you get the benefit of expert travel advice.

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Get It Together Before You Go

2010-04-16T14:36:00.007-04:00

Perhaps the most stressful part about traveling is getting everything ready before you go. Keep a checklist in a document file that you can refer to before each trip so that you will worry less about forgetting something essential.

Use a document neck holder in the airport or train stations, so that you can have both hands free but keep your travel documents safe and readily accessible at all times. Choose a wallet just for travel that is small enough to carry only essential items. Think about preventing pick pockets and keep your wallet in your front pants pocket, around your neck or in a purse slung across your shoulder.

What I need to bring

Tickets- air, bus, and/or train
Passport and any travel visas
Travel /health insurance information
Copies of my passport, Visas, and extra passport photo kept separate from originals
Driver’s license (even if you aren’t planning on driving – it’s a back up photo ID)
Copy of itinerary, address, phone number for inside your luggage tags
Send yourself an email with your itinerary, medical history/medication list, passport number, and emergency customer service numbers for your credit card company
Confirmation documents for hotel, activities, etc.
Photocopy of any essential prescription drugs you take
Copy of your eyeglass prescription

Take only the essential items from your regular wallet. Take only the credit card(s) or ATM card that you will need for this trip. Leave everything else at home.

Once you make this list, it will be a time saving tool you will use over and over again.

Costa Rica - A Snap Shot

2010-04-02T07:50:00.011-04:00

Are you looking for a great vacation in an exotic locale with stunning natural beauty, miles of pristine beaches, wildlife, snorkeling, kayaking, nature walks and even zip lining through a tree top canopy? Check out Costa Rica.

We arrived in San Jose and spent 2 days in Monteverde in the cloud canopy. Walking on the suspension bridges through the rain forest made you feel small in the lush greenery but one with it all. The smells of moist ferns, the sound of howler monkeys in the distance and the touch of rain- vertically and horizontally were exhilarating.

Then we boarded the Pacific Explorer in Los Suenos and spent the next 10 days cruising the Pacific coast, visiting national parks, deserted islands, botanical gardens and transited through the Panama Canal under the guidance of four highly educated naturalists. We swam, snorkeled, hiked, and took photography walks with Dennis Finn, a professional photographer, who helped us see this beautiful place through light, color and composition. My point and shoot camera never pointed and shot so well!
Costa Rica is clean and the food fresh and healthy. We had our hepatitis A shots and prescriptions for ciprofloxin to be prepared for traveler’s diarrhea. We used 30 % DEET to prevent mosquito bites but didn’t need malaria prophylaxis. We actually saw very few mosquitoes and bugs in general. I did get a bite in the water that might have been a small jelly fish and used After Bite Extra right away and it worked instantly. Most everywhere we went people spoke or understood English or my limited Spanish.
So consider Costa Rica. Check with your local travel clinic to see what you would need as it will vary based on your exact itinerary and planned activities. Pura vida!

Top Ten Travel Tips for Every Traveler

2010-03-27T07:22:00.005-04:00

1. Be sure you are fully immunized. Check with your primary care provider or
travel clinic 4-6 weeks before travel if possible.

2. Be familiar with food and water precautions for your destination.

3. Know where the nearest US consulate is located.

4. Pack a first aid kit specific for your itinerary.

5. Don’t go barefoot.

6. Prevent bug bites to prevent bug borne illnesses.

7. Take out trip health and emergency evacuation insurance.

8. Use the right sun protection.

9. Register with the US State Department before you go.

10. Wash your hands! Wash your hands! Wash your hands!

Fun in the Tropical Sun

2010-03-22T14:09:00.002-04:00

When I decided to go to Panama and Costa Rica my biggest concern was how this fair-haired, green eyed , freckled traveler would survive the tropical sun. I am proud to say that with a little attention to detail- I didn’t burn.

• Choose a sunscreen with at least 30 SPF. I used 50 SPF since I was in the
sun constantly.
• Select a water- and sweat-resistant product that provides protection against both UVA and UVB rays. Apply ½ to 1 hour before exposure if possible.
• Use at least 1 oz of sunscreen for total body application (i.e., quarter of a 4-oz bottle).
• Apply to all exposed areas, especially the ears, scalp, lips, back of the neck, tops of the feet, and backs of the hands. For snorkeling, I hiked up the back of my bathing suit and used sunscreen there so that when my bathing suit rode up a little from kicking, my bottom was protected. I also remembered to apply it behind my ears.
• Use spray for hard to reach areas.
• Reapply after 1–2 hours and after sweating, swimming, or toweling (even on cloudy days).
• Many sunscreens lose potency after 1–2 years.
• Sunscreens should be applied to the skin before insect repellents.
• Avoid products that contain sunscreens and insect repellents. (DEET-containing insect repellents may decrease the effectiveness of sunscreens and may increase absorption of DEET through the skin.
• Cover up. I wore a long sleeved high SPF sun protective shirt when I snorkeled. It dried quickly and was very comfortable.
• Don’t forget a hat and sunglasses.

Keeping Track of Important Travel Information

2010-02-05T10:02:00.002-05:00

Losing your passport, airline or hotel confirmation number can be a nightmare. Many people will make multiple copies and take those with them. But here’s a better idea - I send myself an email with all my important information.

If you get separated from your group, get lost, injured, or worse, you will likely end up in an airport, hospital, embassy, military or police station where internet access is available just about anywhere in the world. If you have a Gmail or Yahoo account, you can access your email from any computer. Don’t have a Gmail or Yahoo account? You can still send yourself an email and retrieve it at www.mail2web.com. It’s free. Type in your email address and password and there is your email.

I send myself my passport, itinerary, the international telephone number for my credit card company customer service line, immunization records, important medical records and medication lists, hotel confirmation numbers and telephone numbers, and anything else you might think helpful. Keeping track of important travel information easily gives you peace of mind.

Thinking about going to Haiti?

2010-01-19T13:40:00.006-05:00

The disaster in Haiti has left all of us wondering what we can do to help. Many of us have donated money and some are going to help. If you are considering going to Haiti to volunteer, here are some things you need to know.

The CDC has developed guidelines for relief workers and others traveling to Haiti. Check this site frequently for updates.

Before you depart you must have all your routine vaccinations current - tetanus and diphtheria, measles/mumps/rubella (MMR), polio, seasonal and H1N1 flu and chickenpox (varicella). You will also need hepatitis A and B and typhoid.
If your departure is eminent, accelerated schedules of hepatitis A and B can be given. Even one dose will afford some protection.

You must take measures to prevent insect borne diseases, such as malaria and dengue fever. This includes taking prescription medications and using insect repellent with DEET.

Haiti has a high prevalence of HIV infection. To reduce the risk, always wear gloves when coming in contact with blood or any body fluids or touching any surfaces soiled with such. Find out from your group if you need to bring your own gloves.

Tuberculosis rates in Haiti are very high. A tuberculin skin test is recommended before you go and 6-8 weeks after you return. If you will be having direct contact with TB patients, wear an N-95 respirator mask.

Anthrax occurs in Haiti and is transmitted by direct contact with infected animals or with contaminated products from infected animals.

A visit to a travel health clinic is important prior to your trip for immunizations and prescriptions. If you think you are going to go, call your local travel health clinic and get prepared now.

Cozy in coach?

2010-01-12T12:06:00.005-05:00

Are those seats getting smaller? Flying coach seems to be getting more and more uncomfortable. If you plan ahead and pack a few items on your carry-on you can improve that.

Avoid dehydration. Bring bottled water on the plane. Make sure to purchase bottled water after you’ve gone through security.

A small bottle of soothing eye drops such as artificial tears is a welcome relief. Keep lips hydrated with lip balm. I keep both in a small sandwich sized zip lock bag that I put inside my quart sized zip lock bag for security. Once I’m through security, it’s easy to pull out just what I need for on the plane.

Have back issues? Bring a self inflating seat cushion to support your back and hips. Neck issues? Bring an inflatable neck collar, so that no matter what position you’re in, your head is supported when dozing.

Many people complain of headaches while flying. Preventing dehydration helps but so will noise cancelling head phones. That constant drone of the engines is greatly reduced and you won't be subjected to someone else's conversations. A cool eye mask blocks light and reduces headaches and eye puffiness.

Think about making it easier to maneuver around in small rest rooms. Wear loose fitting clothes without belts. Shoes that are easy to get on and off and allow for a little swelling are also a wise choice.

With a little forethought, riding coach can be a little less uncomfortable.

Personal first aid kits for traveling

2010-01-09T07:22:00.011-05:00

What you need to bring for a personal first aid kit will depend on your health, where you are going and how long you will be there. Here are some suggestions of what to bring for a 2-3 week trip to a tropical area in an under developed country. Remember to bring small amounts in small tight containers that are well labeled.

Band aids made of cloth not plastic (they can melt)
Alcohol preps- those foil packets of alcohol pads about 10
Sunscreen - waterproof SPF 15 higher
Lip balm with SPF 15 or higher
Soothing eye drops or artificial tears
Tweezers and small scissors ( put in check on bag not carry on)
Duct tape - take a toilet paper cardboard tube and cut in half and wrap a few yards of duct tape around it to make a small roll
Small tube of triple antibiotic cream (ointments can melt)
Bug bite cream - 1% hydrocortisone cream, diphenhydramine cream or a product such as After Bite
Prescription medicines in original labeled bottles
Anti diarrhea medicine - available over the counter
Acupressure wrist bands for motion sickness
Mild laxative tablets
Aspirin or ibuprofen or acetaminophen (depending on what you can take based on allergies, health problems and concurrent medications - if in doubt ask a health professional)
Emergency dental kit

If you wear contact lenses you may want to leave them home. Lack of clean water makes proper handling and cleaning contacts a problem. The dryness of the airplane and dust on safari make wearing contacts uncomfortable.

There are first aid kits available that have most of the above all prepackaged. If you don't use it on this trip, there is always the next!

Packing for a Safari

2010-01-08T21:10:00.006-05:00

Packing for a safari is different than packing for other types of trips. Pack light! Be able to get everything in a duffel bag or soft sided suitcase. Find out if you have a weight restriction and abide by it. Pack your essentials such as your camera, prescriptions, money, travel documents, yellow certificate of vaccination and passport in your carry-on bag. Leave your jewelry at home. If you couldn’t bear to lose it – don’t bring it. Flashy jewelry and clothes, especially red, are not appreciated by the wildlife!

Suggestions for packing

A pair of comfortable walking shoes that are broken in
A pair of closed toe sport type sandals
Underwear, socks, pj’s
Bathing suit for pools at the lodge
2 long sleeved shirts ( light colors are best)
2 short sleeved shirts
1 pair of shorts
2 pairs of long pants (consider the type that zip off into shorts)
Wide brimmed hat and 2-3 cotton bandanas
Lightweight fleece pullover
Toiletries – consider body wash that can be used as cleanser and shampoo in
one, hand sanitizer, travel size tooth brush and paste, etc. (think small and
water proof containers)
Face cloth
Day pack for carrying camera and supplies, binoculars (7 X 28 or 8X 21),
sunscreen, lip balm, hand sanitizer, etc.
Sunglasses
Insect repellent with 30 % DEET or more
Zip lock bags in various sizes
Travel alarm clock
Small flashlight

Plan on wearing everything 3 times. Most camps have laundry service. Remember, it’s not a fashion trip, be comfortable and dress to protect yourself from the sun and bug bites.

Avoiding Mosquitoes 101

2009-12-21T15:43:00.005-05:00

Did you know that the animal responsible for more human deaths than any other is actually an insect and it’s the mosquito? Mosquitoes transmit diseases by biting someone with a virus and then injecting that virus into the blood of the next human it bites. And so on…. It’s a very efficient way to spread the viruses that cause such diseases as encephalitis, West Nile, yellow fever, malaria, dengue fever and chikungunya.

Different mosquitoes transmit different diseases. The mosquito that spreads malaria only bites from sunset to sunrise but the mosquito that transmits dengue fever bites during the day.

Some of these diseases only occur in tropical areas but some, such as dengue fever, as now seen in Southern Florida. West Nile and other forms of encephalitis affect many different areas of the US.

Treatment for most of these diseases is supportative. Therefore it’s best to prevent them.

How to avoid mosquito bites:

1. Cover up. If it’s hot wear light weight clothing- long sleeved shirts, pants and shoes instead of sandals.

2. Treat your clothing with permetherin , which is insecticidal. You can buy pre treated clothes (expensive) or do it yourself by spraying or soaking clothes and air drying ahead of travel. Treated clothing will stay active for 6 weeks and several launderings. If using mosquito nets, treat them, too.

3. Use 30% DEET on exposed skin and reapply as needed based on locale, swimming and perspiring. Don’t forget your scalp, ears and feet. Mosquitoes are very good at finding any exposed area they can! Avoid contact with your eyes, mouth and any open areas. DEET products come as sprays and wipes.

4. Don’t use products that attract mosquitoes such as perfumes, scented products, including hair spray.

So, be aware of where mosquitoes reside and protect yourself.

My Favorite Travel Tips

2009-11-09T16:50:00.004-05:00

Here are just a few of the things I have found so helpful when I travel.

Email yourself before you leave. Send yourself an email with your itinerary, passport number, and immunization and health records. There is almost nowhere in the world that you that you won’t be able to access your email.

Bring a hair scrunchie. You know those covered elastics. Find a bright colored one. When you travel to a country where you can’t drink the water out of the faucet – put the scrunchie on the faucet as a visual reminder not to automatically grab a toothbrush or glass and drink.

Don’t go barefoot. Bring a pair of flip flops – you can even wear them in the shower for protection and traction. They don’t take up much space. This way you avoid stepping on or in things you don’t want to and helps prevent getting cut and bitten.

Have tissues or toilet paper with you all the time. Even in the USA there are lots of places when you find yourself stranded.

Smile. It’s the most important thing I bring with me wherever I go and it has helped me in more situations than almost anything else – except when I got detained in the airport in St Petersburg, Russia a few years ago, but that’s another story….

Rabies and Traveling

2009-11-09T16:39:00.008-05:00

Most of us in the U.S. don’t think about rabies unless we have pets and have to innoculate them. But in most parts of the world, animals are not immunized for rabies. Each year it kills 50,000 people, mostly children, as it is spread by bites and when saliva from an infected animal gets into the eyes, nose, and mouth or through broken skin. Dogs account for most cases but foxes, raccoons, monkeys and bats are also sources of infection. Rabies is almost 100% fatal in humans. So what should travelers do to protect themselves and their families from rabies?

Avoid animal bites by avoiding touching all animals, including wild animals and pets. Pets in other countries may not have been vaccinated against rabies. Supervise children closely, especially around dogs, cats, and wildlife, such as monkeys. This is important since children are more likely to be bitten by animals, may not report the bite, and may have more severe injuries from animal bites.

If you are going abroad for an extended period of time or will work around animals, or spend time in wilderness areas, consider getting pre exposure vaccination to rabies. This will not prevent you from getting rabies but will enable you more time to get treatment. Act quickly if an animal bites or scratches you.

Wash the wound thoroughly with soap and water. See a doctor right away, even if you don’t feel sick or your wound is not serious. To prevent rabies, you may need to start a series of vaccinations immediately. Be prepared to travel back to the United States or to another area for treatment adequate vaccination for exposure to rabies is not available in all parts of the world.

Before your trip, find out if your health insurance covers health care overseas and medical evacuation. If it does not, consider buying supplemental health insurance for your trip.

Why Don't We Bill Insurance?

2009-10-06T07:08:00.003-04:00

This is probably the most frequently asked question we get. Some clinics, especially those associated with a medical center, do bill insurances. Most private travel clinics don’t. Instead clients are given forms with all the necessary information to submit to their insurers for possible, direct reimbursement.

Most insurers do not cover travel vaccines. Medicare does not cover travel vaccines at all. (They only cover flu and pneumonia and hepatitis B under very limited circumstances and herpes zoster vaccine under optional plan D). The reimbursement rate for vaccines is slightly above or below the cost of the vaccine. Vaccine prices rise faster than reimbursement rates do. To make up for this, an administrative fee for each vaccine is added. Some clinics that do not bill third parties charge administration fees, too. Most don't. The office charge for a clinic that bills in our area is about $250. Those that don't bill direct charge much less. We charge $85 per person or $100 for two people traveling together.

So, what do we tell the consumer?

We tell them to call their insurer and ask if they cover travel health office visits and travel vaccines. They have to ask specifically about travel vaccines or they may find out that they were told they were covered but that they didn’t mean yellow fever. If they cover it all, they can go to a clinic that bills direct or may still choose to go to one that doesn’t and submit the form themselves. If you do not bill insurance you still need an NPI number and need to give the clients statements with proper coding. Other factors that determine how consumers choose travel care are location, convenient hours and the reputation of the clinic.

Even though we have client's that don't come to us because we won't bill, I don't regret that business decision. It would cost us alot more to bill and collect fees that were denied by the insurer because they were not covered, had a high deductable, etc. Because we don't bill, I can spend more time providing direct client care than dealing with administraive and billing problems.

Typhoid Vaccine - Oral or Injectable?

2009-08-18T15:59:00.005-04:00

There are many different places in the world that travelers need to protect themselves from typhoid fever. Salmonella Typhi is bacteria carried the bloodstream and intestinal tract. It is shed by persons with the infection and by carriers in their stools. Typhoid fever is contracted by eating food or drinking fluids that have been handled by a someone who is shedding the bacteria.

It can be spread by sewage contaminating the water used for drinking or washing food. Travelers from the United States to Asia, Africa, and Latin America are at risk.

Light green areas are endemic

Dark green areas are highly endemic

Symptoms range from mild to severe and include fever as high as 103° to 104° F, weakness, abdominal pains, headache, diarrhea and loss of appetite. In some cases, patients have a rash of flat, rose-colored spots. Diagnosis is made by stool culture. Treatment is with antibiotics and prevention and treatment of dehydration.

So how do you decide which vaccine to give to patients who are traveling?

The injectable vaccine is well tolerated but costs more and lasts only 2-3 years. The oral vaccine is a series of four capsules given every other day so it takes a week to complete it and then a week for it to become effective. It needs to be stored properly, refrigerated , or it loses potency. It must be taken on an empty stomach (one hour before or two hours after eating) and can’t be taken concurrently with antibiotics , alcohol or with very hot or cold beverages. To enhance patient compliance Berna, the manufacturer, has a very good informative booklet, reminder cling decals for the bathroom mirror and refrigerator and an animated video http://www.oraltyphoidvaccine.com/.

They have an absent minded patient program where they will replace a vaccine for free if you sent it back when the patient hasn’t taken it properly. So if you have a compliant patient with enough time, it makes sense to offer the oral vaccine and save your patient some money and give patient 5 years worth of protection and one less shot . If time is short, and you or your patient decides the oral regimen is too complicated, you can give the injection.

Food and water precautions are still recommended because of all the other food and water borne pathogens. Remember to counsel your patients to
Boil it. Peel it. Cook it. Or forget it!

Planning Ahead and Being Prepared

2009-08-05T07:02:00.003-04:00

Every year in the Fall I stock up on a few essentials in anticipation of another New England winter. This year I am doing it a bit early in anticipation of H1N1 outbreak. It’s not that I am an alarmist or pessimist but I like to be prepared. I am asking my patients to think about what they would need at home if they couldn’t get out to the grocery store or pharmacy for a few weeks and suggesting that then plan ahead. Here's what I think we need to tell our patients.

Have enough nonperishable groceries on hand to last at least 2-3 weeks. Make sure you have enough of the essentials, such as toilet paper, soap, hand sanitizer, laundry detergent, and tooth paste, stocked up.

Check to see if you have enough acetaminophen and cough syrup on hand in proper doses for the entire family.

Evaluate your prescriptions. Is there anything that you couldn’t go without for a month? If so, get an extra month’s supply and set it aside in a safe place.

Keep a small amount of cash on hand in case you can’t get to the bank.

Got pets? Make sure you have enough food, litter, and pet meds for an extra month.

If you are putting off any repairs that if put off could be a big problem, just get them done.

Keep you gas tank full.

It’s easy to live week to week since banks, groceries, gas stations and pharmacies are readily available but what if supplies became scarce? What if you didn’t want to go out in public? If this Fall is uneventful then we will all be prepared for the next weather related event or public health threat. There’s no harm in being prepared.

Give a better shot.

2009-07-20T10:57:00.003-04:00

What do most adult patient’s fear almost more than anything else? Shots. Why do patient’s come up with so many excuses not to get vaccinated? Fear of shots. Why do lots of adults (and health care providers) avoid the flu vaccine every year? Yup, afraid of shots. Why don’t more people take advantage of travel health clinics? Because they are worried about the shots.
So, how can you change this? Give a better shot. I’ve been giving shots for over 30 years and I give over 1,000 flu shots alone every year. Here’s my thought on this or what I like to call…
Nancy’s Needle Tips
Like any procedure, first learn the technique, and then perfect it. But don’t stop there. Now learn how to do it quickly and efficiently without sacrificing the quality. Speed is good.
If you don’t feel comfortable giving an injection, you will project that to the patient. If you need help, seek out a mentor, practice and perfect your skills and build your confidence.
Don’t aspirate. If you learned how to give an injection more than a few years ago, this may sound like heresy. According to the CDC, it is not necessary to aspirate when giving an injection. It makes the task harder, takes longer and hurts more.
Don’t linger. Draw up all injections at once, away from the patient’s view. Keep the needle discreetly out of view and tell the patient right before the procedure what you are going to do. Ask them to hang their arm down and make it loose and then just do it. Have the patient apply pressure or rub it.
You don’t need gloves for an injection. It takes more time to put them on.
Distract them. I call this “vocal anesthesia”. Don’t discuss how everyone hates shots. Don’t even talk about shots. Ask about work, school, their kids, and their trip.
Offer an ice pack. I keep Boo Boo Kitty, my ice pack, in my refrigerator. (Yes, for the adults). I like to keep an assortment of specialty band aids for them to choose. I think Dora the Explorer is nice for the travel clinic.
And last, but not least, I praise the patient. I tell them they did a good job and that I know how hard that was for them to get that shot/s. All of these techniques help make getting a shot a little more pleasant this time and helps set the stage for the next one.

How many of your patients are fully immunized?

2009-07-15T07:28:00.002-04:00

Take every opportunity to update your patient’s routine immunizations. Most patients’ don’t know their immunization status and don’t have records. So how can you find out? Look at previous primary care records, emergency room records (especially for wound care), college/high school records, military records, and don’t forget Mom. I have my original pediatric immunization records that my mother saved from over 50 years ago. Check to see if your patient has a “yellow book”, an international certificate of vaccination. If no records exist, then begin updating considering the recommendations for tetanus, diphtheria, pertussis, influenza, pneumococcal disease, MMR, varicella, herpes zoster, hepatitis A and B.

Here’s a list of resources to help you increase the immunization rates for routine immunizations for adults in your practice.

2009 Immunization schedule for adults for the U.S. with footnotes
VIS-Vaccine Information Statements are required by law to be given to patients. 30 languages other than English are also available.
Needle Tips is an e newsletter all about vaccinations for adults and children.
Do I Need Any Vaccinations Today? Is a handout you can leave in your waiting area for patients to consider for themselves and other family members? Many patients ask me about this and it helps to remind me to use every opportunity I can to immunize.
Immunization Screening Questionnaire is available to photocopy or purchase a tear off pad to use as a timesaving tool to prescreen contraindications for vaccination.
Immunization records may be available free from your state’s public health department or may be purchased inexpensively from immunize.org

There are 3 types of immunizations to consider when preparing a patient for international travel.
1. Routine- what every adult in the U.S. needs
2. Recommended- what the traveler needs because of possible exposure on this trip
3. Required- what is needed for entry into a specific country (i.e. yellow fever vaccine)

If your patients have all of their routine immunizations up to date, they will need fewer shots for their upcoming trip.

Does Travel Health fit into your primary care practice?

2009-07-12T08:19:00.000-04:00

Despite the current state of the economy, many people are traveling. Immigrants return home to visit friends and relatives. Students travel abroad to study and do humanitarian work. Church groups offer tours that combine missionary work and vacations. People, who can’t find work here, travel to find jobs. People who can’t afford certain medical procedures in the U.S. are traveling abroad for what is now called medical tourism. And of course, those who can are taking advantage of worldwide discounts in vacation travel.

As a primary care provider, you will be asked for health advice for travel. You will need to decide which patients you can advise and which you will want to refer to a travel health specialist.
So, how do you decide? First, evaluate your level of expertise in travel health. Do you understand the destinations and types of itineraries your patients are taking? Do you have the knowledge to evaluate when malaria chemoprophylaxis is warranted and which drug to choose? Do you understand all of the travel vaccines and drug and other vaccination interactions? Are you current with the latest evidence based recommendations for self treatment for traveler’s diarrhea ?

Do you have the time in your practice to devote to travel health? A typical travel health visit in my practice involves about one and half hours for the preparation, research, visit, charting and follow up. Medicare and Medicaid will not reimburse you for travel health visits or most vaccines. Medicare B covers pneumonia and flu vaccines and hepatitis B in very high risk patients only. Medicare D covers herpes zoster vaccines in varying degrees. Most private third party insurers do not cover travel visits, most vaccines or malaria medications if used for prophylaxis. Third party payers typically reimburse at cost or less than your cost for immunizations. Only certified yellow fever centers can administer yellow fever vaccine. If your patient is traveling to an area where yellow fever is required or recommended, you will need to refer to a certified yellow fever centers.

After gaining expertise in this field, I choose to set up a travel health clinic as a separate entity from my primary care practice. Travel Health of NH, PLLC is a fee for service practice that does not bill or accept any insurance. As a family nurse practitioner in the state of New Hampshire, I am able to operate my own practice and prescribe independently. You will need to check with your state's laws to determine your legal scope of practice.

So, you can refer all your travel patients or offer some travel health services within your level of expertise in your primary care practice. Or you could add to your education and start a travel health practice separate from your primary care practice. No matter what level of involvement you choose, the most important thing you can do for all your patients is make sure all their routine adult immunizations are current and documented.